How to put millions of Americans back to work safely

There is mounting pressure to get the economy moving again by lifting social distancing and letting people go back to work - on Sunday, President Donald Trump reiterated his view that as we fight the covid-19 pandemic, "The cure cannot be worse than the problem itself. We've got to get our country open."

But it's imperative not to repeat past mistakes: During the 1918 Spanish Flu epidemic, premature lifting of social distancing restrictions caused second waves of epidemics in several major cities of the United States, the United Kingdom and elsewhere. The question is whether there is a way to put people back to work safely - and how large a workforce this could be.

The answer is yes, and the number is in the millions.

Between 1.4 million and 3.5 million Americans could safely reenter the workforce over the course of the epidemic. The specific group is composed of immune survivors of covid-19, the disease caused by the novel coronavirus, who were not hospitalized, who are between the ages of 20 and 59 and who are in the potential workforce.

In 2014, two of us were among the scientists who proposed a similar strategy in response to the Ebola epidemic, dubbing it MORE, or "Mobilization of the Recovered." The idea is to get those who've already had the disease, and developed some immunity, into roles needed for society to function. To varying degrees, it can work in all countries affected by covid-19 today. In the U.S., the potential is great. Here's why.

The case fatality rate of a disease is the fraction of infected people who die of it - the number of deaths divided by the total number of cases. A simple idea, but also a moving target: Due to incomplete testing, we may not detect all cases; and because the figure will differ by age group, region and other factors. Based on Centers for Disease Control and Prevention figures as of April 6, we estimate a case fatality rate of about 2.5% for the country as a whole, meaning that about 97.5% of Americans who contract covid-19 would survive the disease.

Based on our understanding of other coronaviruses such as SARS and MERS - and the results of a non-yet-peer-reviewed March study in monkeys of covid-19 specifically - covid-19 survivors will be immune to reinfection, for several months at least, and possibly far longer.

As the nation's top infectious-disease expert, Anthony Fauci puts it, "It's never 100%, but I'd be willing to bet anything that people who recover are really protected against reinfection." They likely also won't be able to transmit the virus by coughing, sneezing or other respiratory channels. While they would still be able to transmit by touching contaminated surfaces, this risk can be minimized through improved workplace sanitation and personal hygiene.

Most important, when a blood test to detect antibodies - not the same as the test to detect the virus itself - becomes available, we will be able to identify this immune group. Once we have the antibody test, able-bodied adults in this group could reenter the workforce without risk to themselves, and with minimal risk to others, in some cases, returning to their former jobs or filling in for absentees until these can return to their previous employment, if still possible.

This same immune group could be deployed as a supplemental health-care workforce to perform myriad non-specialized functions including hospital facilities maintenance, laundry, disposal, transport of patients, distribution of supplies, supervision of elderly patients and other jobs needed to meet surge hospital demand.

And while there's nothing beneficial about the spread of covid-19, one potentially useful feature of our approach is that this immune pool grows in proportion to the number of infections, so the potential labor force is growing fastest roughly when the epidemic itself is. Which is just when we need it most.

This all applies, of course, to able-bodied adults. In this group, we include people between 20 and 59 years of age (53% of the population based on the most recent Census estimates) who have not been hospitalized (86% of those, based on New York City data) and are in the potential workforce (80% of those, based on Bureau of Labor Statistics data).

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Pulling all of this together, we estimate that the fraction of those infected with covid-19 who could safely rejoin the economy: the 97.5% of the infected population who survive, multiplied by the 53% between ages 20 and 59, multiplied by the 86% who were never hospitalized, multiplied by 80% who are or were in the workforce. The product is our estimate that 36% of those infected by covid-19 will be able to safely rejoin the workforce within a few months.

The absolute number of workers this represents depends, of course, on an estimate of the total number of cases. Last week - after months of downplaying the threat - the White House conceded that there could be between 100,000 and 240,000 deaths, after Fauci said the U.S. may have "millions" of cases. How many cases would there have to be to result in 100,000 deaths?

If there's a 2.5% case fatality rate, as estimated above, there would have to be 4 million cases, of which 36% would be a labor force of 1.4 million. The number increases in proportion to one's estimate of the final death toll of the epidemic. Using the same calculus, the federal government's upper-end projection of 240,000 deaths translates to 3.5 million workers who could safely go back to work.

The essential point is that, even under conservative plausible assumptions, a very significant labor pool, numbering in the millions, will be available to restart the economy without restarting the epidemic.

A few caveats: It's important that the resources, human and otherwise, needed to do widespread antibody testing not detract from the real-time treatment of active cases - there are still crucial shortages of skilled medical personnel, personal protective equipment and resources necessary to actually administer testing on the required scale.

Additionally, this plan requires a highly accurate antibody test. It is essential that any test being used correctly identify immunity against the novel coronavirus without unacceptable levels of false negatives and false positives.

There is also an equity dimension: Those of us who can continue doing our jobs by telecommuting need not physically hurry back to work or take temporary jobs in the health-care sector, which do carry risks, such as infecting loved ones through surface transmission. Fair compensation for those who do go back to the physical workplace would recognize these remaining risks.

We must avoid a second wave of covid-19, a virtual certainty if we abruptly lift distancing in the midst of the epidemic. But there is an evidence-based way to start slowly bringing those of us who've already had the disease back to work. It would be reckless for everyone to rejoin the economy at once, but millions of us can, and safely.

(COMMENT, BELOW)

Epstein is a professor of epidemiology at the NYU School of Global Public Health, where Hatna is a clinical associate professor of epidemiology and Jones is an epidemiology doctoral student.